1. Field of the Invention
The invention relates generally to analysis of pharmaceutical benefit plans for determining, for example, whether a specific pharmaceutical benefit plan is suitable for a member thereof and/or for providing the member specific information to make informed decisions with respect to the pharmaceutical benefit plan. In addition, the invention relates more specifically, to providing information with respect to alternative pharmaceutical treatments, including recommending lower cost alternatives for mediations, when appropriate.
2. Description of the Related Art
Pharmaceutical benefit plans are a component of many health insurance plans. They offer coverage (payment) for medications that are prescribed for a wide variety of conditions. Pharmaceutical benefits plans are not standardized, and vary in the coverage and additional costs that patients are expected to pay. Additionally pharmaceutical benefit plans are becoming increasingly complicated and detailed. In this application, the term medication will be used to describe all medications that are recommended and/or prescribed by a doctor for a patient, including biologics, brand name drugs, generic drugs, and over the counter drugs.
Typical features of various pharmaceutical benefit plans include co-payments for every purchase or refill of a medication, coverage for certain medications at only a percentage of cost, no-coverage for other medications, or benefit caps. Additional features may be limitations on the number of re-fills or for long term use of a medication. To reduce costs for an insurer, many pharmaceutical benefit plans do not cover more expensive patented medications when generic or non-patented medications that are therapeutically equivalent or substitutable. Generic medications are non-patented medications identical to medications that were previously patented, and are usually available at substantially reduced costs. Therapeutically equivalent medications may not be identical, but may treat the same disease in a very similar manner, for example, statins used for treating high cholesterol. Multiple statins exist that can treat the condition, and the are therapeutically equivalent, but not identical. Over the counter medications are medication that are approved for purchase without a prescription, they can be patented or unpatented. However, we have determined that members are not able to access the necessary information to make informed decisions. In addition, we have determined that pharmaceutical benefit plan members are not able to control what types of medications to take (or not take) that might be appropriate for their specific condition. Further, we have determined that members are not able to make independent decisions based on best practices and/or medical information.
What is needed is a way of obtaining and/or purchasing medications that will treat a patient's conditions, but in way that reduces costs in view of a patient's pharmacy benefit plan. In addition, we have determined that what is needed is a system and computer implemented method that empowers pharmaceutical benefit plan members to make informed decisions on whether and what medications may be appropriate for their health conditions, in a manner that reduces overall costs.